Ketorolac for Analgesia followiNG Autologous Breast RecOnstructiOn

Breast reconstruction (BR) is commonly requested following mastectomy, and recent measures have been taken to ensure patient access is universal. Transferring autologous tissue from the abdomen using microvascular surgical techniques provides a reliable reconstruction method with high levels of patient satisfaction, and is routinely performed. However, the surgery is relatively complex and lengthy; operative times can exceed six hours and hospital stay ranges from 5-9 days. During each patient's postoperative course she must meet certain milestones before discharge. It has been shown that beyond the necessary monitoring of the viability of the free flap, pain and a patient's ability to mobilize are important modifiable barriers to discharge.

Pain control following autologous BR is multimodal, but predominantly relies on opioids. Narcotics provide effective analgesia, but have a well-known side effect profile that includes drowsiness, nausea, vomiting, sedation, central nervous system and respiratory depression. Each of these potential adverse effects limits patients' mobility after surgery. Respiratory depression is particularly disadvantageous, as these patients have undergone major abdominal musculature dissection that also disrupts their mechanics of breathing 10 . This may have the counterproductive effect of limiting patient mobilization, and ultimately delay discharge. In a health care system where resources are at a premium and costs are climbing, any inexpensive intervention that allows for an earlier and safe discharge is worthy of consideration.

No standard approach to postoperative pain control in free flap BR exists. Most protocols are institution dependent, and variably incorporate narcotics, nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen and other agents. In addition, these medications are given via oral, intramuscular, or intravenous routes. Recent studies have investigated the use of transversus abdominis plane blocks as an analgesic adjunct, and patients are often provided with patient-controlled analgesia (PCA) pumps in the early postoperative period.

Ketorolac tromethamine is an NSAID, which is approved by Health Canada for short-term pain control (Toradol, Hoffmann-La Roche Limited, 7070 Mississauga Road Mississauga, Ontario). Ketorolac provides better pain control than the most commonly used NSAIDs, and its potency is comparable to that of morphine. However, it does not have the same listed side effects of drowsiness and respiratory depression as do narcotics. Surgeons often cite concern regarding postoperative bleeding when using NSAIDs, however recent reviews have convincingly demonstrated the safety for use of NSAIDs in plastic surgery. A previous observational study has also shown the safety of ketorolac specifically following autologous BR. The routine addition of ketorolac following surgery has been shown to reduce patients' narcotic requirements in other fields of surgery, such as orthopaedics and gynaecology.

Given the abovementioned advantages of ketorolac, and the particular propensity for abdominally based free flap BR patients to be negatively affected by narcotic side effects, we hypothesize that the addition of ketorolac to a routine multimodal postoperative analgesia regimen will reduce hospital stay by a day or more.